MSK Flashcards
Difference between strain and sprain
Sprain = injury to ligament
Strain = injury to tendon
Feature of 3rd degree strain
muscle tears all the way through
‘pop’ sensation – muscle rips into 2 or shears away from tendon
Symptoms of ankle sprain/strain
- Swelling
- bruising
- pain after injury
Most common ankle sprain
inversion ankle sprain = where excessive plantar flexion and supination cause the anterior talofibular ligament (ATF) to be affected.
What imaging is used to identify fractures/dislocation?
x-ray
When is x-ray indicated in ankle fractures?
Clinical exam with Ottawa rules:
X-rays are only necessary if there is pain in the malleolar zone and:
- Inability to weight bear for 4 steps
- Tenderness over the distal tibia
- Bone tenderness over the distal fibula
What is fibromyalgia?
Widespread pain throughout the body with tender points at specific anatomical sites.
Features of fibromyalgia
- Chronic, long term, widespread pain >3months
- -> Pain in back and neck, or “all over”
- -> Worsened in cold weather, stress, activity, and associated morning stiffness - Additional symptoms: fatigue, trouble sleeping, memory difficulties, mood difficulties
- O/E: diffuse tenderness, with 11/18 tender trigger points (used less and less in practice)
Diagnosis is clinical
Define polymyalgia rheumatica
Inflammatory condition causing pain in the hip and shoulder girdles.
Pain NOT weakness
–> in older people characterised by muscle stiffness and raised inflammatory markers.
Features of polymyalgia rheumatica
- usually rapid onset (e.g. < 1
- aching, morning stiffness in proximal limb muscles
- also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats
Investigations for polymyalgia rheumatica
Raised inflammatory markers : ESR > 40 mm/hr, elevated CRP
What symptom is not associated with polymyalgia rheumatica?
weakness
What is gout?
- Form of inflammatory arthritis
- Uric acid crystal deposition in joint causing episodic acute swelling/pain in joint(s).
- monosodium urate monohydrate in the synovium
Features of gout
- Painful swollen joint - can mimic septic arthritis
- Acute
- Sudden onset of pain lasting 1-2wks
- Spontaneous but may have trigger
- Big toe, ankle joint, finger joints, elbow
- Skin is red and shiny, swollen and hot, tender
- VERY PAINFUL – SHEET CANNOT TOUCH TOE
- May have associated skin findings, Tophi (stone)
- Intermittent attacks of acute joint pain, very tender, red - Typically first presentation is the 1st MTP - PODAGRA
Gold standard for gout
Joint aspiration and crystal analysis.
Negatively birefringent crystals
Other investigations for gout
- Serum uric acid levels- may be raised
- ***PEARL: Patients may have chronic raised uric acid but during an acute attack, uric concentrations may fall and uric acid during a flare is not a good diagnostic test
- Leucocytosis, raised ESR and CRP during acute attack
What are the radiological features for gout?
- joint effusion is an early sign
- well-defined ‘punched-out’ erosions with sclerotic margins in a juxta-articular distribution, often with overhanging edges
- relative preservation of joint space until late disease
- eccentric erosions
- no periarticular osteopenia (in contrast to rheumatoid arthritis)
- soft tissue tophi may be seen
What is pseudogout?
Form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium
Features of pseudogout
- knee, wrist and shoulders most commonly affected
- joint aspiration: weakly-positively birefringent rhomboid-shaped crystals
- Red, hot swollen, episodic attacks.
Investigation for pseudogout
- x-ray: chondrocalcinosis
- -> in the knee this can be seen as linear calcifications of the meniscus and articular cartilage
What is rheumatoid arthritis?
Systemic, Inflammatory Joint disorder
What is osteoarthritis?
AKA “degenerative joint disorder” as it is a degenerative form of arthritis that gets worse with age and is associated with overuse.
Clinical features of osteoarthritis
- All joints can be affected: mostly knees, hip, hands, lumbar and cervical spine
- Worse with more activity and use
- Joint pain and disability
- Affects one or more weight bearing joints - Decreased ROM + function, joint crepitus, deformity, effusion, muscle weakness, wasting
- Joint pain without or without stiffness. Pain»_space;>Stiffness
- Symptoms increase with activity; diminish with rest
- Usually little or no swelling or redness of adjacent tissues
- Heberden’s nodes (DIP) - (osteophytes on distal interphalangeal joints)
- Bouchard’s nodes (PIP) - (osteophytes on proximal Interphalangeal joints)
Joints affected by Osteoarthritis vs Rheumatoid arthritis
Osteoarthritis = Large weight-bearing joints (hip, knee)
Carpometacarpal joint
DIP, PIP joints
Rheumatoid arthritis = MCP, PIP joints
How is osteoarthritis diagnosed?
1st line = x-ray:
- Loss of joint space/joint space narrowing (because of cartilage loss)
- subchondral sclerosis (cysts)
- osteophytes (new bony formation)
Clinical features of Rheumatoid arthritis
- Predominantly peripheral joints (hands,feet)
- Ulnar deviation
- Swan neck deformity (hyper extended PIP, flexed DIP)
- Boutonniere (hyper extended of DIP, flexed PIP)
- Z thumb deformity (hyperextension of interphalangeal joint) - Polyarthritis (multiple joints)
- Symmetrical joint pain, effusions, soft tissue swelling
- Functional loss (especially in the hands)
- Progresses to joint destruction and deformity
- Tendons may rupture; bone alignment affected
- Systemic signs of inflammation (fever, malaise, anorexia)
- Early morning stiffness that doesn’t get better/worse with activity/time
What test would you carry out in rheumatoid arthritis?
Positive squeeze test
- discomfort on squeezing across the metacarpal or metatarsal joints
How do you diagnose rheumatoid arthritis?
Anti cyclic citrullinated peptide antibody (anti CCP) is the most SPECIFIC test for rheumatoid arthritis.
- If you have CCP+, you likely have RA
Investigations for rheumatoid arthritis
- Rheumatoid factor – positive in many patients, but not as specific.
- anti CCP = positive in RA
- ESR and/or CRP increased (inflammatory joint disease)
- ANA titre positive in some patients
- Xray findings: Erosions of bone
Define osteoporosis
- Thinning/weakening of the bones putting patients at risk for fractures.
- Mild thinning is called Osteopenia. Severe thinning is called osteoporosis.
Symptoms:
• ASYMPTOMATIC UNTIL A FRACTURE APPEARS. Osteoporosis
Risk Factors for osteoporosis
- post-menopausal women
- increasing age
- smoking
- steroid use
- low BMI
Symptoms of osteoporosis
ASYMPTOMATIC UNTIL A FRACTURE APPEARS.
Diagnosis of osteoporosis
Diagnostic: DEXA scan
- Look at the T score on a DEXA scan.
T score = 0, normal bone density. Your bones are as strong as people your sex/age
- T score >0, good bone density. Your bones are stronger than people your age/sex
- T score between -2.5 and 0, osteopenia
- T score > -2.5 = osteoporosis
Define Pagets disease
Disease of increased but uncontrolled bone turnover.
- It is thought to be primarily a disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity.
clinical features of paget’s disease
Symptoms: only 5% are symptomatic
1. older male with bone pain and an isolated raised ALP
- bone pain (e.g. pelvis, lumbar spine, femur)
- classical, untreated features: bowing of tibia, bossing of skull
- raised alkaline phosphatase (ALP) - calcium* and phosphate are typically normal
- other markers of bone turnover include: procollagen type I N-terminal propeptide (PINP), serum C-telopeptide (CTx), urinary N-telopeptide (NTx), and urinary hydroxyproline
Investigation for Paget’s disease
- Bloods:
- raised alkaline phosphatase (ALP)
- calcium* and phosphate are typically normal - other markers of bone turnover include:
- procollagen type I N-terminal propeptide (PINP)
- serum C-telopeptide (CTx)
- urinary N-telopeptide (NTx)
- urinary hydroxyproline - skull x-ray
- thickened vault, osteoporosis circumscripta
Renal bone disease: basic problems in CKD
- Low vitamin D (1-alpha hydroxylation normally occurs in the kidneys)
- high phosphate
- low calcium: due to lack of vitamin D, high phosphate
- secondary hyperparathyroidism: due to low calcium, high phosphate and low vitamin D
Clinical manifestations of renal bone disease
- Osteitis fibrosa cystica
aka hyperparathyroid bone disease - Adynamic
- reduction in cellular activity (both osteoblasts and osteoclasts) in bone
- may be due to over treatment with vitamin D - Osteomalacia
- due to low vitamin D - Osteosclerosis
- Osteoporosis
Complication of vitamin D deficiency
Osteomalacia – softening of the bones secondary to low vitamin D levels
- In turn leads to decreased bone mineral content
Symptoms of vitamin D deficiency
- Bone pain
- Bone/muscle tenderness
Investigations for vitamin D deficiency
Diagnostics:
- Bloods – low vitamin D, calcium, phosphate
- Raised ALP - X-Ray – translucent bands
What is metabolic bone disease?
Disorders of bone strength usually caused by abnormalities of minerals (such as calcium or phosphorus), vitamin D, bone mass or bone structure
What is Reiter’s syndrome also known as? 2B
reactive arthritis
Define reactive arthritis 2B
an arthritis that develops following an infection where the organism cannot be recovered from the joint.
Classic presentation of reactive arthritis 2B
‘Can’t see, pee or climb a tree’
Features of reactive arthritis 2B
- Time course
- typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months - arthritis is typically an asymmetrical oligoarthritis of lower limbs
- dactylitis
- symptoms of urethritis
- eye
- conjunctivitis
- anterior uveitis - skin
- circinate balanitis (painless vesicles on the coronal margin of the prepuce)
- keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
What is Polyarteritis nodosa (PAN)? 2B
vasculitis affecting medium-sized arteries with necrotizing inflammation leading to aneurysm formation.
Features of Polyarteritis nodosa (PAN) 2B
- fever, malaise, arthralgia
- weight loss
- hypertension
- mononeuritis multiplex, sensorimotor polyneuropathy
- testicular pain
- haematuria, renal failure
- perinuclear-antineutrophil cytoplasmic antibodies (ANCA)
What is polymyositis? 2B
- inflammatory disorder causing symmetrical, proximal muscle weakness
- thought to be a T-cell mediated cytotoxic process directed against muscle fibres
- associated with malignancy
Features of polymyositis (2B)
- proximal muscle weakness
- +/- tenderness
- Raynaud’s
- respiratory muscle weakness
- interstitial lung disease: e.g. fibrosing alveolitis or organising pneumonia
- dysphagia, dysphonia
Investigations for polymyositis (2B)
- elevated creatine kinase
- other muscle enzymes (lactate dehydrogenase (LDH), aldolase, AST and ALT)
- EMG
- muscle biopsy
- anti-synthetase antibodies
What is scleroderma? (2B)
uncommon condition that results in hard, thickened areas of skin
- sometimes problems with internal organs and blood vessels.
Features of scleroderma (2B)
tightening and fibrosis of skin
may be manifest as plaques (morphoea) or linea
What is Sjogren’s syndrome?
2B
autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces.
Features of Sjogren’s syndrome
2B
- dry eyes: keratoconjunctivitis sicca
- dry mouth
- vaginal dryness
- arthralgia
- Raynaud’s, myalgia
- sensory polyneuropathy
- recurrent episodes of parotitis
- renal tubular acidosis
Investigation for Sjogren’s syndrome
2B
- rheumatoid factor (RF) positive in nearly 50% of patients
- ANA positive in 70%
- anti-Ro (SSA) antibodies in 70% of patients with PSS
What is Juvenile idiopathic arthritis? (2B)
arthritis occurring in someone who is less than 16 years old that lasts for more than 6 weeks
- Systemic onset JIA is a type of JIA
Features of systemic onset JIA
2B
- pyrexia
- salmon-pink rash
- lymphadenopathy
- arthritis
- uveitis
- anorexia and weight loss
Investigations for Juvenile idiopathic arthritis (2B)
- ANA may be positive,
2. rheumatoid factor is usually negative
What is Systemic lupus erythematosus (SLE)? (2B)
A chronic multi-system autoimmune disorder
- most commonly affects women during their reproductive years
- can affect any body system
Features of SLE (2B)
General
- fatigue
- fever
- mouth ulcers
- lymphadenopathy
Skin:
- malar (butterfly) rash: spares nasolabial folds
- discoid rash: scaly, erythematous, well demarcated rash in sun-exposed areas.
- photosensitivity
- Raynaud’s phenomenon
- non-scarring alopecia
MSK:
- arthralgia
- non-erosive arthritis
Cardiovascular
- pericarditis: the most common cardiac manifestation
- myocarditis
Respiratory
- pleurisy
- fibrosing alveolitis
Renal
- proteinuria
- glomerulonephritis
Neuropsychiatric
- anxiety and depression
- psychosis
- seizures
Investigations for SLE (2B)
Antibodies:
- ANA positive
- –>This means if you someone has a negative ANA, they do not likely have lupus. If someone has a positive ANA, use clinical judgement. IS NOT DIAGNOSED FOR SLE - dsDNA+
- Less sensitive but more specific for SLE than ANA
- Rarely found in healthy patients
- Generally diagnostic for SLE - Complements (C3 and C4)
- used to track disease activity. Low complements (low C3 and C4) suggest higher disease activity - Anti-Sm (Anti smith) – very specific for SLE
What is Slipped Upper Femoral Epiphysis?
Displacement of the femoral head epiphysis postero-inferiorly
Risk Factors for Slipped Upper Femoral Epiphysis
- typically age group is 10-17 years
- More common in obese children and boys
- Males > Females
Features of Slipped Upper Femoral Epiphysis
- hip, groin, medial thigh or knee pain
- Limp with leg externally rotated,
- loss of internal rotation of the leg in flexion
- restricted range of motion (ROM) on exam